“…I heard of a new medical school: East Tennessee State University. It had started a residency program in internal medicine. As residents we would rotate through the Mountain Home Veterans Administration Medical Center (the “VA)—a veritable town within the town of Johnson City—as well as the adjacent Johnson City Medical Center (the “Miracle Center”) a community hospital. The rural setting in the foothills of the Smoky Mountains, in the shadow of the Appalachian Trail, seemed a beautiful place to bring my bride.” –Abraham Verghese, My Own Country: A Doctor’s Story (21).
In the memoir of his time practicing medicine in Tennessee, Abraham Verghese tells an immigrant’s story and a story of healthcare, but aspects of My Own Country that stand out, yet could be easily overlooked, are the strong sense of place he invokes and the social association that is endemic to the Appalachian region. I borrow the idea of “social association” from the field of sociology, where the term is used to describe how communities are more tightly bound together because of various threads in a social fabric, such as religion, schools and universities, politics, and social groups. According to the Sociology Institute: “At its core, an association is an organized group of individuals who come together to pursue a common goal or shared interest.” Because Appalachians display a high degree of social association, especially as it concerns place, this phenomenon is also a useful tool in analyzing medical memoirs from the region. Since I live and work in Appalachia, it’s the context I know best. However, the lessons learned from studying social association in a health humanities context within Appalachia may be useful to the practice of medicine in other rural places, as well.
Verghese’s memoir became known to me as I began my work in narrative medicine in West Virginia. When I designed a course, Medicine and the Arts, for first- and second-year honors students at the institution where I formerly taught, I chose specifically Verghese’s book over other well-known and more recently published work because of its rootedness in Appalachia. I thought this might speak to students, drawing on their own experience of place, as well as the qualities that pertained to the healthcare they would practice within the region. As it turned out, I was right.
Early, during his time in the US and Appalachia, Verghese moonlighted in small emergency rooms along the border of Virginia and Tennessee. Almost immediately he encountered social association:
The ER nurses were on a first-name basis with every patient that came in. the ambulance drivers rarely resorted to the “forty-three-year-old-white-maile-with-chest-pain-unrelieved-by-nitroglycerin” jargon. One was more apt to hear on the scanner that “Louise Tipton over on Choctaw Hollow says Old Freddy’s smothering something awful and we better get over there right away, ‘cause it’s worse than the time when he came in and Doc Patel put him in the breathing machine.” (20)
Verghese first experiences Appalachia as an outsider, and in time makes inroads into the social relations that characterize local life in eastern Tennessee and southwest Virginia. One of his first friends, a nurse named Essie who is also a local, could find work outside the small community, but did not attempt to look for it. He observes that “The tiny communities nestled in the hollow and connected to each other by narrow mountain roads provided a security that made city life difficult to contemplate. Her parents and her brother and cousins all lived within a mile of each other” (Verghese, 21). Something other than opportunity kept her in the region. Verghese’s tone throughout the early part of the book is distant yet respectful, and his status as an outsider is punctuated by his reaction to the local cuisine his co-workers, also locals, ply him with, including ramps, a pungent wild onion that grow throughout Appalachia during a short window in the spring.
What is particularly interesting about the early part of Verghese’s book is that while he attempts to characterize the experiences as authentically Appalachian, commenting on family ties and deep accents, he does so with a deep appreciation that the culture is different from the pejorative stereotypes he had often heard about Appalachia. Because of the influx of foreign doctors into the region, Verghese and his wife could attend parties with Indian doctors and their families where they would experience a familiar Indian culture, yet they could also “don jeans and boots and go line dancing at the Sea Horse on West Walnut or listen to blues at the Down House” (23). In a study of the counties that make up the southern coalfields of West Virginia, “most participants had an experience to share in which they or a family member was treated with disrespect because of where they lived” (Coyne et al., 3). Given what we know about the prevalence of negative Appalachian stereotypes, a close and sensitive reading of Verghese is imperative to understand his stance, as a physician, toward those around him, and his own “reading” of the Appalachian culture. (We could also study this in relation to the HIV patients he treats in this area; however, such analysis would merit at least another full article.)
An interesting aspect of Verghese’s memoir is that he has the opportunity to leave Appalachia. He completes a fellowship in Infectious Disease in Boston, but there is a lingering effect of first living and working in Appalachia that makes adapting to Boston more difficult. “Three years in Tennessee has gotten us used to making eye contact with people anywhere and automatically exchanging a ‘How you all doing?’ or at least a nod,” Verghese writes. “But in Boston, neighbors discouraged this sort of familiarity” (32). So, when a position in academic medicine opened at ETSU, he took the opportunity to return to Appalachia: “We looked forward to returning to Appalachia; we were ready for a less frenetic existence in a corner of rural America that we loved” (33). What’s particularly interesting about these passages is that they reflect on the qualities that many native Appalachians cite as being important aspects about the place they live. The study of the southern coalfield counties in West Virginia, for instance, reveals a common theme:
A deep sense of place emerged from all focus group discussions and was exemplified by the attachment participants felt to “their mountains” and the sense of belonging they verbalized. Most respondents stated that they could not understand why anyone would want to leave the state. A few who left for a short time to work elsewhere reported they could not wait to get back. (Coyne et al., 3)
This idea of being a part of a specific mountain place is echoed by Verghese, strongly highlighting his own growing social association as a result of living within the region:
When I justified to friends in the Northeast my decision to settle in the South, I found myself talking not about the natural beauty of the place, or its climate, or the mountains you could see in every direction, or the lakes, rivers and innumerable streams where you could fish. It was the people [emphasis his] of east Tennessee and southwest Virginia that drew me. (41)
Verghese writes of the term “good ole boy” as the highest compliment bestowed by locals, one that he wishes to be associated with, and when his closest friend, Allen, who runs a local service station refers to Verghese as both “Doc” and a “good ole boy,” he knows he has made some inroads into assimilating. There are many instances of this throughout the memoir, but these examples illustrate the strong link between social association and assimilation. This association builds a level of trust and familiarity that will allow him to do the important medical work that the rest of the memoir recounts. Without that association, that task would be nearly impossible in a place like rural Tennessee, which makes it particularly interesting as an object of study for those in the health humanities.
One of the most recent reports on health disparities by the Appalachian Regional Commission, the Robert Wood Johnson Foundation, and the Foundation for a Healthy Kentucky, is already woefully out of date, having been released in 2017. While there are many significant findings in the report, some highly concerning data includes:
Every mortality indicator is higher in the Region than in the nation overall: heart disease is 17 percent higher; cancer is 10 percent higher; COPD is 27 percent higher; injury is 33 percent higher; stroke is 14 percent higher; and diabetes is 11 percent higher. Considering death broadly, YPLL, a measure of premature mortality, is 25 percent higher in the Region than in the nation as a whole. (Marshall et al., 6)
This is one set of data among many that show the significant health issues faced by Appalachians. We also know that cultural forces, like Appalachian fatalism, contribute to poor health outcomes. Regional health advocate Wendy Welch describes Appalachian fatalism: “Also called learned helplessness, mountain stubbornness, hardiness, and sometimes loss of control, fatalism has an odd history in the region” (108). With ample research on health disparities and growing attention to cultural forces like Appalachian fatalism, becoming more adept at recognizing and building social association in Appalachia can, perhaps, have significant positive impact on health outcomes and well-being in the region.
Religion, family cohesion, friendship, health, and integrity were highlighted among the cultural factors studied by Coyne et al (4) within Appalachia. Due to lower levels of medical familiarity and a cited distrust of physicians, many patients within the region consult a health professional only as a last resort. Another aspect of Coyne et al. that relates specifically to My Own Country concerns an influx of foreign doctors to the region: “Some participants expressed concern about a lack of American-born physicians in their geographic area and seemed disgruntled about having to see a foreign-born physician for medical care” (5). This is particularly interesting in light of Verghese’s memoir. In fact, Verghese writes about other foreign-born doctors who do not understand the importance of social association and therefore do not seek to assimilate into the local culture in the way he does. Verghese describes the situation of a second-year resident who is as resistant to the local culture as the locals are to him: “Aziz was full of himself; too taken with the fact he was a doctor. His personality, both public and private, revolved around that fact . . . it made them connect his boorishness to his foreignness—they were one and the same thing” (45). Absorbing the locals’ contempt, Verghese writes of an overwhelming desire not only to set himself apart from his colleague, but to provide contrasting example for the locals:
I was not from his world, nor was I his keeper, to the degree that he generated these negative impressions it affected all the rest us of foreigners. Perhaps I consciously over-achieved, worked hard to make up for Aziz, did everything to earn for myself the appellation “good ole boy.”
But Aziz was long gone now, a mere memory.
And I was back and looking to settle in Tennessee . . . I wanted nothing more than to settle in one place and be a good physician. Stateless and roaming for so long, I wanted to put down roots. . .
Johnson City was going to be my town. I felt at peace in this corner of east Tennessee. Finally, this was my own country. (45-46)
We can wonder how many doctors from other parts of the country (or world) come to work and live in Appalachia lacking any sense of social association with the patients they serve. We might also speculate about Verghese’s ability to truly assimilate into the Appalachian context he so dearly desires. And we might fairly debate, philosophically, whether it is, or should be, a foreign physician’s responsibility to do the work of assimilating in order to more effectively practice medicine. However, when we consider Verghese’s approach as a technique employed by a physician in order to build a level of comfort and trust with patients that differ from him, we may find there are broad applications for building associations within communities like Appalachia where place identity is strong. This may pertain to cases where race and ethnic background are not relevant factors but where regional background—where the physician is from—may impact how that physician is received by the community.
The work of Coyne et al. also acknowledges the breadth of diversity within the many counties that make up Appalachia, as not to treat it as a monolithic culture, but a robust culture with many vibrant subcultures:
It is important for scientists and medical practitioners working with Appalachian communities to understand the culture of the area. It is not sufficient to rely on dated scholarly or popular literature that portray stereotyped Appalachian characteristics and culture or on overgeneralized attitudes and beliefs that may apply only to a subgroup of people. As many social scientists and geographers have begun to realize, Appalachia is a region of diverse people and resources. Physicians, health educators, policy makers, and behavioral scientists need to recognize this diversity so that health communities can work together to address the health needs of Appalachia America. (Coyne et al, 6)
This study was published in 2006, and I might suggest adding health humanities researchers and the scholars of narrative medicine to the list of individuals who are called to recognize the diversity of Appalachia, as they may also offer significant contributions to discussions of social association within Appalachian healthcare. Poor health outcomes in Appalachia have been exacerbated by the COVID-19 pandemic, where narrative medicine may be a particularly useful intervention because it “is an accessible, diversity-honoring, low-cost, underutilized pedagogical framework with potentially revolutionary benefits for enhancing patient care, supporting the underserved, mitigating clinician burnout, and improving team dynamics” (Loy and Kowalsky, 93). Because it provides space for individual narratives, such as Verghese’s memoir, as well as collective narratives, such as studies of communities within Appalachia, it represents an exciting approach that might potentially bridge many of the gulfs in Appalachian healthcare in a way that honors individual experience as well as the social association that already exists within these communities. Used in group settings, as advocated by Loy and Kowalsky, narrative medicine approaches can leverage “the power of social connections in health” (94). Furthermore, the study of physician memoir in the region, such as My Own Country, can help prepare practitioners from outside the region for work inside the region.
This is only a starting point for healthcare and health humanities work. It would be particularly useful to compare these ideas concerning social association in Appalachia to other regions that serve rural populations. There may be critical overlap with significant relevance, allowing physicians to build stronger relationships with their patients, and fortifying rural healthcare by addressing gaps in available clinical care, high incidence of chronic disease, and other negative impact outcomes. Perhaps we might, as Abraham Verghese writes in the last sentence of his book, “remember the acts of human kindness that illuminate our world” (429). That human kindness is like a fog swaddling a mountain ridge, and it might settle over the rugged terrain of Appalachia if we let it.
Works Cited
Coyne, Cathy A., Cristina Demain-Popescu, and Dana Friend. “Social and Cultural Factors Influencing Health in Southern West Virginia: A Qualitative Study.” Preventing Chronic Disease: Public Health, Research, Practice, and Policy, vol. 3, no. 4, Oct. 2006.
Loy, Michelle, and Rachel Kowalsky. “Narrative Medicine: The Power of Shared Stories to Enhance Inclusive Clinical Care, Clinician Well-Being, and Medical Education.” Permanente Journal, vol. 28, no. 2, 2024, pp. 93-101.
Marshall, Julie, et al. Health Disparities in Appalachia. Appalachian Regional Commission, 2017, https://arc.gov/report/health-disparities-in-appalachia/. Accessed 8 Mar. 2025.
“Understanding Associations: Definitions and Societal Roles.” Sociology Institute, 10 Dec. 2022, https://sociology.institute/introduction-to-sociology/understanding-associations-definitions-societal-roles/. Accessed 8 Mar. 2025.
Verghese, Abraham. My Own Country: A Doctor’s Story. Vintage Books, 1995.
Welch, Wendy. “Self Control, Fatalism, and Health in Appalachia.” Journal of Appalachian Studies, vol. 17, no. 1/2, Apr. 2011, pp. 108-22. EBSCOhost, https://doi.org/10.2307/41446937.